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x • \rJ l APPLICATION FOR PERMITD �,.� r; SAN JOAQUIN LOCAL HEALTH DISTRICT h 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone ) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED oil (Complete pE II (Complete in Triplicate) l Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 'M Y Job Address City Lot Size PM OwAd ner's Name dress Phone t T t �--dr- Cdntractor Address ��. C _License No �/ _Phone -i .l k TYPE OF WELL/PUMP: N W WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ i! PUMP INSTALLATION SYSTEM RE7R ❑ OTHER ❑ j o- DISTANCE TO NEAREST: SEPTIC TANK —F -- SEWER LINES DISPOSAL FLD. I� PROP. LINE y�.,4A.C� k - J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO14S �. + 0"Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well!ICasing f r omestic/Private- =s 171 Gravel Pack ❑ Tracy Type of Casing.10e s ____ _ .,r..Specifications__._��...w..----...-.-.. f),Public_ r 0 Other. F1 Delta Depth of Grout Seal Ty e of Grout C6 ¥ I I Irrigation .. _ _Appraz. Depth i I Eastern Surface Seal Installed by F Reh � M1•� y yy : j. pair Work Done ❑ Type of Pump :7H.P. 75. State Work Done _ -WeN Destruction ❑ Well Diameter /b Sealing Mats'rial (top 501 h Depth 119 Fill'er,MSt al'(Below.50% I 41r'7 ' � `.'TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRlADDITION l I DESTRUCTION I I Mo"septic.sys.tem-permined.if_publi.c-sewe[_iS—.,;, available within 200 feet.) Installation will.serve:' Re'sidencer`�'CommerCial �`F Other: II ".!"be t Number of living units: rNumber of bedrooms ` !I i r Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments II :PKG. TREATMENT PLT. ❑ F - { Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines j Total length/size I FILTER BED ❑ Distance to nearest: �ot Well Foundation Property Line SEEPAGE PITS l I Depth �' Size Number s SUMPS X1 Distance to nearest: Wei! Foundation Property Line r T 4_DISPOSAL-,PONDS s "Ell t I hereby certify-that F have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or•siib-contracting signature ' certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicantu t call for I re ' d ins tions. Complete drawing on r arse side. Signed X Title: Date: `�� If 9 � I FOR DEPARTMENT USE ONLY / Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Or- i f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ii FEE AMOUNT DUE AMOUNT REMITTED s CASHCK 41, BY DATE PERMIT"ND- r INFO ��^^ - a EH 13-24(REV. G`v Y 1� tij EH 14-2a Q i